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111111 II~IIII~IIIIUI~II~IIAlllllllll
NUM ,~us we 11 /-~ cAJ..
RD. COMP X ~ ~~~1z
COMPARE ~~
CADAS _ AO
ADAMS COUNTY, NE
FILED
INS? NO..,..~.Q.Q ~ ~ 81 "~
Date -3-08 Time~:~~iYt.
~~~;~~
REGISTER OF DEEDS
The south 33~• feet of the Southveet quarter the City of Hastings. Adams County, Nebraska
(S'Wy) of Lot ],3. Block 1, Buswell~e Addition to according to the recorded plat thereof
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i
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND:HUMAN SERVICES
SYSTEM, ?CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINALRECORD'ON t+IlE-WITH
THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATI$T~S~.~CT10~-{h!FI1CH IS .
THE LEGAL DEPOSITORY FOR VITAL RECORDS. i. ,_ / y~ - ~ ., '~ O Q 8 O 81
' DATE OF ISSUANCE j_C/l( /~,/ "~(_j}
8 1 0 2 0 0 4 =- ~ _ANLEY S. GOOP~R~
ASS/STAAiT 3iATE REGI~I~AR
LINCOLN, NEBRASKA HEALTHAND Hl~MAN SERVICES ~YSIEM ~ .
--_ -. ~ s. __ -. -
i STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERKICES~INANCE AND SF~FORT _
VITAL STATISTICS - ?-~ - 'J c ~y
CERTIFICATE OF DEATH - ~. , ~`.~ ~~`+ O ~ `~ ~ ``'
1. DECEDENT -NAME FIRST MIDDLE LAST 2. SEX' 3. DATE OF DEATH /Month. Day. Year) -
Martin H. __ Hansen Male, '' July 31 , 2004
4. CITY AND STATE OF BIRTH lIl not in U.S.A.. name country! Sa. AGE - Lasl Birthday UNDER 7 YEAR UNDER 1 D-AY 6. DATE OF BIRTH /Month, Day. Year)
A ra Kansas
g - (Yrs.) 83 Sb. MOS. DAYS
' Sc. HOURS' MINS.
Jul 23 1921
7. SOCIAL SECURTIY NUMBER Ea. PLACE OF DEATH
51
~
3 -1 2 - 6 3 5 4 HosPITAL: ^ Inpatient OTHER: ® Nursing Home
- _-
.
Bb. FACILITY -Name (/loot institution, give slreel and number) ' , ^ ER Outpatient ^ Residence
Rerlesawi~Haven Home ^ DDA ^ Gther/SpacrN,
8c. CITY. TOWN OR LOCATION OF DEATH 8d. INSIDE CIT'{ LIMITS 8e. COUNTY OF DEATH
•..
9a. RESIDEPICE - STATE 9b. COUNTY 9c. CITY. TOWN OR LOCATION 9d. STREET AND NUMBER /Including Zip Cadet ~ 9e. INSIDE CITY LIMITS
I .Nebraska Adams 8901
Colorado Yes ~ No ^
Hastin s 726 N
.
10
RACE
Whit
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Bl
k
A
I
di
11
ANCESTRY l
It
li
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M
G
.
-
mer
e.g.,
e.
ac
.
can
n
an.
.
e.g..
a
an.
ez
can,
erman, etc/ 12. ~ MARRIED ^ WIDOWED 13. NAME OF SPOUSE (l! wile. give maiden name)
i eta,tBpeci") IspeC1"I O al Hansen
R DIVORCED p
WHite American
MARR
~- -
14a. USUAL OCCUPATION /Give kind of work done during moss 14b. KIND OF BUSINESS INDUSTRY 15. EDUCATION ISDecily only highest grade completed)
j of workrAg file, even it retired!
Machinist
Fact .Elementary or Secontlary 10-12) College 11-4 or SCI
or 12 1
16. FATHER -NAME FIRST MIDDLE LAST 17. MOTHER FIRST MIDDLE MAIDEN SURNAME
Carl Hansen Anna Jensen
18. WAS DECEASED EVER IN U.S. ARMED FORCES? 19a. INFORMANT-NAME
(Yes, no. or unk.) III yes, give war aM dates of services/ T,7T,T
yY V~
''
YES ., ~
_ ;,
-1 3 ..
19b. INFORMANT MAILIN ADDRESS (STREET OR R.F.D. NO.. CITY OR TOWN. STATE, ZIP)
726 N. Colorado Hastin s Ne 68901
20. EMBA ER -SIGNATURE 6 LICENSE NO.
./' y (~~})/p~~
" /~1~`i /y~--'v•L^~ 1 ,
'
~~/'----
21a. METHOD OF DISPOSITION
®Burial ^Removal
27 b. DATE
August 3, 2 __
21 c. CEMETERY OR CREMATORY NAME
Gardens
04 Sunset ~Memorail
' 22a. FUN HOME -NAM/V 21 d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE
Brand-Wilson Funeral Home ^Cremation ^Donaaon Hastings, .Nebraska
22b. FUNERAL HOME ADDRESS (STREET OR Fl.F.D. NO.. CITY OR TOWN. STATE, ZIP)
505 N. Bellevue, Hastings, Ne 68901
23. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR lat. Ib), AND Icll ~ Interval between onset and death
PART I
'
Congestive Heart Failure
lal
DUE TO, OR AS A CONSEQUENCE OF I Interval between onset and tleath
I
l .'hl - I -
_ i
DUE TO, OR AS A CONSEQUENCE OF. I Interval between onset and death
I
Icl I
I
OTHER SIGNIFICANT CONDITIONS -Conditions contributing to the death buI not related
PART PART III IF FEMALE. WAS THERE A 24 AU~fOPSY 25. WAS CASE REFERRED TO MEDICAL
II PREGNANCY IN THE PAST 3 MONTHS? EXAMINER OR CORONER?
(Ages 10-54) Yes No Yes No X Yes No
26a. ~ 26b. DATE OF INJURY (MO.. Oay. YrE 26c. HOUR OF INJURY 26d. DESCRIBE HOW INJURY OCCURRED
Accident ~ Undetermined
M
Suicide ~ Pending 26e. INJURY AT WORK 26t. PLACE QF,INJURY - Al home. /arm, street. lactory
o Ice building
eta /Speed
/ 26g. LOCATION STREET OR R.F.D. NO. CITY OR TOWN STATE
^
Homicide Invesligalion ^ ^
Yes No ,
y
27a. DATE OF DEATH /Mo.. Day. Yr.J 28a. DATE SIGNED /Mo.. Day. Yrl 28b. TIME OF DEATH
July 31
2004 =w
>s< , ~ v = M
y 27b. DATE SIGNED /Mo.. Day. Y<l 27c. TIME OF DEATH ~ i C } 28c. PRONOUNCED DEAD /MO.. Day, Yr./ 28d. PRONOUNCED DEAD /HOUrI
~ g° AM
~~"'~ 1 1 : 4
Au
ust 3
0
4 ~ s ~ o
n g ,
g
,
,,
~
~
M g z~ M
a 27d. To the best of m no I ge. {teeth oc t ime,Qat~ d place an
d
~ v
~ "28e. On the basis of examination and~or investigation, in my opinion death occurred al
causelsl state
~
/
' ° o the time, dale and place and due to the causels) staled.
~ !
-
ISi nature anQ T'
ISi nature and Title -
29. DID TOBACCO US R UT DEATH? 30.a HAS ORGAN OR TISSUE DONATION BEEN CONSIDERED? 30.b WAS CONSENT GRANTED?
® YES ^ NO ^ UNKNOWN ^ YES ® NO ^ YES ~ NO
.,....,...."....,r,.,.,,,~,,,, .., .,~..,,, ,~,.,i ,,,o,.,, ,~~...~,,.~..a rr„a~~o.,. u.. wurvir niivnrveri Irype ar rnnq
Robert Mastin MD, 1021 W. 14th, Hastings Nebraska 68901
32a. REGISTRAR ~ 32b. DATE FILED BY REGISTRAR /MO.. Day. Y.1
~U~ ~ 200